NSMP 321 2022 - Study Guide (Final)

NSMP 321 EC
NURSING SCIENCE PRACTICE:

MEDICAL & SURGICAL III
Faculty of Health Sciences
Study guide compiled by:
Dr N Scheepers
Copyright © 2022 edition. Review date 2023.
Geen gedeelte van hierdie studiegids mag in enige vorm of op enige manier sonder skriftelike toestemming van die publiseerders weergegee word nie.
No part of this study guide may be reproduced in any form or in any way without the written permission of the publishers.
It all starts here
 Ranked in the top 5% of universities globally by the QS-rankings
 Contribute the second largest number of graduates annually to the labour market
Dit begin alles hier

 As een van die top 5% universiteite wêreldwyd deur die QS-ranglys aangewys
 Lewer jaarliks die tweede meeste graduandi aan die arbeidsmark
Gotlhe go simolola fano

 Re beilwe mo gare ga diyunibesiti tse 5% tse di kwa godimo go ya ka peo ya
maemo ya QS
 Ngwaga le ngwaga go abelwa palo ya bobedi ka bogolo ya badiri mo maketeng
ya badiri
ii
MODULE CONTENTS
MODULE INFORMATION...............................................................................................ii
STUDY MATERIAL........................................................................................................iv
MODULE PLAN..............................................................................................................v
MODULE PROGRAM....................................................................................................vi
PRACTICE ATTENDANCE...........................................................................................vi
TEACHING-LEARNING OPPORTUNITIES.................................................................vii
ASSESSMENT PLAN..................................................................................................viii
EXAMINATION MARK.................................................................................................viii
MODULE MARK..........................................................................................................viii
NSMP 321 GENERAL INFORMATION.........................................................................ix
SUMMATIVE ASSESSMENT........................................................................................xi
ASSESSMENT SCALE.................................................................................................xii
STUDENTS WITH LEARNING DIFFICULTIES AND DISABILITIES...........................xii
WARNING AGAINST PLAGIARISM............................................................................xii
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MODULE INFORMATION
Module code NSMP 321
Module name Nursing Science Practice: Medical & Surgical III
16 C
Module credits This implies that you must spend a total of 160 hours to
master the outcomes of this module successfully.
NQF level 7
Use this guide concurrently with the theoretical guide

Prerequisites
NSMS 321 Nursing Science: Medical & Surgical III
Additional resources Access to the Internet, eFundi and study material

or requirements to indicated in this study guide.
complete module
successfully
Mahikeng Campus
Name of lecturer Ms. Tabea Motsilanyane
Building A 13
Building and Office
Office telephone 018892534
no
Office
Email address 22063447@nwu.ac.za
On appointment. A day for student weekly consultation will

Consulting hours
be specified.
Access to the Internet, eFundi and study material indicated

Additional support
in this study guide.
Name of lecturer(s) Mr. Boitumelo J Molato
Building A 13
Office telephone 0183892636 Building and Office no Office G09
On appointment. Student may request an appointment via

Consulting hours
email or WhatsApp
Addtional support
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Mahikeng Campus Preceptor
Name of lecturer(s) Mr. Tumelo Dintwe
Building A 13
Office telephone 018389 2530 Building and Office no Room G12
Email address Tumelo.Dintwe@nwu.ac.za

Consulting hours
email or WhatsApp
Additional support
Potchefstroom Campus
Name of lecturer(s) Dr. N Scheepers
Building F7
Office telephone 018 2991763 Building and Office no Room 108

Consulting hours
email or WhatsApp
Additional support
Name of lecturer(s) Dr. A van Wyk
Building F7
Office telephone 018 2991884 Building and Office no Room 106

Consulting hours
email or WhatsApp
Additional support
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Potchefstroom Campus Preceptor
Name of lecturer(s) Mrs. Naomi Mahaswa
Building F7
Office telephone 0181813 Building and Office no Room G42

Consulting hours
email or WhatsApp
Additional support
A warm welcome to the practical module Medical Surgical III (NSMP 321). You are therefore
provided with the opportunity to develop your clinical nursing skills (cognitive, psychomotor and
affective) within a safe environment in your third study year, in order to holistically care for a patient
in a specialised unit, by applying the content learned from NSMS 321.
Additional information on instruments, procedures and administrative changes in your schedules
will be posted on the module’s eFundi platform (NSMP 321). Be sure to visit the platform on a
weekly basis to stay informed. We trust this module will provide stimulating, thought-provoking, and
exciting opportunities to learn how to become a knowledgeable, competent, and caring nurse
practitioner.
Consult the University's General Academic Rules as well as the Faculty specific rules that are
available in the yearbook (Faculty of Health Sciences for the curriculum and other requirements of
the programme. The B Cur Guide has been compiled to guide your academic journey as a student
of the North-West University, School of Nursing Science at the Potchefstroom Campus.
MODULE OUTCOMES
On completion of this module students should be able to demonstrate:
 clinical nursing skills in the application of mastered integrated knowledge and an understanding
of all principles and procedures associated with medical and surgical
conditions/disorders/diagnoses of the neurological, renal, gastrointestinal, reproductive,
dermatology disorders and theatre nursing and by applying relevant and appropriate
pharmacology (including EDL).
 the ability to select, assess and apply different diagnostic examinations and appropriate clinical
skills, and to offer evidence-based solutions related to the ethical and legal practice of medical
and surgical nursing care, individually and as part of a healthcare team to resolve health-
related real-life problems.
 the ability to assess the professional conduct of members of a nursing team from varying
cultures and backgrounds and to influence ethical decisions during the care of patients.
 scientific writing skills in the preparation of written reports, clinical workbooks and nursing
records in order to inform other members of a multi-disciplinary medical team of decisions
beneficial to the health of patients.
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 the ability to utilise system-based integrated clinical management guidelines by using an
algorithmic approach concerning an IMCI and adult common symptoms and chronic conditions
(Primary Care101).
STUDY MATERIAL
Books: (In alphabetic order)
ADULT PRIMARY CARE (APC) 2019/2020 Commissioned and published by: The South African
National Department of Health (You can download this guide for free from the internet)
Hinkle, J.C., & Cheever, K.H. 2018. Brunner and Suddarth’s Textbook of Medical–Surgical
Nursing. 13th Edition. New York: Lippincott. (In this study guide referred to as Hinkle &
Cheever)
Mogotlane, S., Mokoena, J., Chauke, M., Matlakala, M., Young, A. & Randa, B. 2018. Juta's
Complete Textbook of Medical Surgical Nursing. 2nd ed. Juta. (In this study guide referred to
as Mogotlane et al.)
Mulder, M., Joubert, A. & Olivier, N. 2020. Practical guide for general nursing science. 2 nd
Edition. Pearson: South Africa
National infection prevention and control guidelines for TB, MDR-TB and XDR-TB (You may
download this document for free on the internet)
Standard Treatment Guidelines and Essential Medicines List for South Africa. (Referred to in
this guide as STG). (You may download this document for free from the internet)
Internet
eFundi
The use of the Internet: the following databases can be used: Nexus, Index to South African
Periodicals, Medline, ASE (Academic Search Elite), Ebsco-med, and World Wide.
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MODULE PLAN
Study unit Study Section
1. The neurological system 1.1 Neurological assessment of an adult (FORMAL)
2. The renal system 2.1 Renal unit visit (Dialysis) (INFORMAL)
2.2 Understanding fluid balance chart (INFORMAL)
3. Gastrointestinal system 3.1 Changing of Total Parental Nutrition (TPN)

(INFORMAL)
4. The reproductive system 4.1 Vacuum drain maintenance (FORMAL)

4.2 Vacuum drain removal (FORMAL)
5. Dermatology 5.1 Assessment of the skin (FORMAL)
6. Theatre Nursing 6.1 Informal theatre skills

6.2 Worksheet on theatre nursing
7. Patient presentation 7.1 Group assignment (case study) FORMAL
MODULE PROGRAM
The practical hour placement roster is available on the Schedule tool on eFundi
PRACTICE ATTENDANCE
Policy on attendance and exam entry, as well as illness and other reasons for absence are
discussed in the A-Rules and B Nursing information guide.
The South African Nursing Council (SANC) requires certain practical hours for MSNP 321. You
will be working a total of 240 hours in General Nursing and Community Health and these hours will
include the following areas:
 Supervised clinical learning in clinical facilities

 Simlab / clinical skills simulation laboratory training (including OSCE)
 Self-directed clinical learning for role taking (weekends)
You will be divided into groups, and you must work accordingly.
TEACHING-LEARNING OPPORTUNITIES
You will be placed in the following areas:
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Mahikeng campus students:
Hospital placements:
 Mahikeng Provincial Hospital
Clinic placements
 Ramatlabama Community Health Care Centre
 Tsetse Clinic
 Lonely Park Clinic
 Unit 9 Community Health Care Centre
 Montshiwa Town Community Health Care Centre
 Montshioa Stadt Community Health Care Centre
 Lekoko Community Health Care Centre
Potchefstroom campus students:
Hospital placements
 Klerksdorp Provincial Hospital
 Tshepong Provincial Hospital
 Potchefstroom Provincial Hospital (for Theatre placement and “Sick-Sundays”
 Anncron Private Hospita
 Wilmed Park Private Hospital
Clinic placements:
 Boiki Thlapi Community Health Care Centre
 Promosa Community Health Care Centre
 Gateway Clinic
 Steve Tsetwe Clinic
 Potchefstroom Clinic
 Lesego Clinic
 Mohadin Clinic
 Top City Clinic
You will also have an opportunity to practise your clinical skills at the School of Nursing Science on
both campuses. You can also schedule a practice session with the clinical skills co-ordinators on
each campus, who will assist you in the Simlab to practice procedures and skills.
Your clinical preceptor / lecturer will schedule the hours on a rotational basis to achieve the
required number of hours:
ASSESSMENT PLAN
Formative evaluation is a continuous process, while summative assessment is performed at the
end of the semester of the year during which the module completes. For the final mark the
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participation mark, compiled from different assignments counts 50% while the examination mark
account for the other 50%.
The assessment plan will also be available on eFundi and is aligned with the General Academic
Rules of the North-West University as approved on 15 June 2012. These rules are in conjunction
with the Assessment and Moderation Policy as approved on 22 June 2007
(http://www.nwu.ac.za/e-yearbook-index) and the Faculty Rules as stated in the General Academic
Rules and in the Yearbook (http://www.nwu.ac.za/e-yearbook-index). Guidelines for assessments
together with the description of action words as used in this module are also available on eFundi.
Assessment plan
See Practical Portfolio
Participation mark
See Practical Portfolio
The participation mark for the degree Baccalaureus Curationis is constituted as follows:
(http://www.nwu.ac.za/e-yearbook-index):
EXAMINATION MARK
Relation between credit marks and examination papers is as follows (http://www.nwu.ac.za/e-
yearbook-index):
a) The examination sub-minimum for all practical modules in Nursing Science is 50%
(General Rule 2.4.3.3).
G.1.2.20 Pass requirements for a module and curriculum and all the subparagraphs are applicable.
b) The pass requirement for a module in which an examination was written, is a
module mark of 50%. (General Rule 2.4.3.1).
c) Consideration for adjusting the module mark of a first level module in which an
examination was written but not passed takes place according to the stipulations of
General Rules 2.4.3.2 and 2.4.3.4.
d) A curriculum is passed if all the comprising modules are passed separately (General
Rule 2.5.1).
Refer to the General Academic Rules (http://www.nwu.ac.za/e-yearbook-index) for information on
second opportunity examinations.
MODULE MARK
A "module mark" is a mark calculated according to a formula which is determined from time to time
for each module in terms of faculty rules, based on the participation mark and the examination
mark awarded to a student in a module; provided that the weight of the participation mark in the
above mentioned formula may not be less than 30% or more than 70% (General Academic Rules -
http://www.nwu.ac.za/e-yearbook-index).
The module mark is calculated as follows:
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 The examination mark and the participation mark in a 50:50 ratio
 Pass mark is 50% (General Academic Rules: Pass requirements).
 75% indicates a distinction (General Academic Rules: Qualification with
distinction).
NSMP 321 GENERAL INFORMATION

 During the course of the year demonstrations on practical procedures will be
provided in SIMLAB, to be formally evaluated on during the year for the Practical
Portfolio. Students will be given a chance to practice the skills they were taught.
 Each student must compile a file titled ‘NSMP 321 - Practical Portfolio’. This file
should be obtained a.s.a.p in the beginning of the semester. You should take
your procedures to placements everyday and be prepared to be evaluated on
any procedure.
Hour lists
Remember to always have your hour list book (register) with you when in practice or in
the simulation laboratory. Be sure to have the sister-in-charge or your clinical preceptor
sign off your hour list book at the completion of each shift. Your hour lists must be
submitted to the clinical preceptor / lecturer (where applicable) on the (4) FOURTH
day of each month, which will in turn capture the hours for your record with SANC to
register you as a professional nurse.
Leave
Annual leave
You have 4 weeks leave for the year. Leave will however be allocated to you by the
clinical preceptor and is non-negotiable. The clinical preceptor will also work out the off
duties which is also non-negotiable. Please note that you will be divided into groups and all
off-duties work in groups. The dates are not negotiable seeing that your placements are
pre-determined for the whole year to ensure that all students get equal opportunity in
practice in order to obtain the number of hours required by SANC.
Sick leave
You are entitled to 12 days’ sick leave per annum. Please submit a legal medical
certificate attached to your hour list which you hand in on the 4 th of every month.
Remember to inform the clinical preceptor, transport coordinator, as well as the lecturers
when you are ill and have been placed on sick leave. Any unprofessional behaviour will
result in further disciplinary steps. Please take note that even though you have sick
leave you still need to work the hours you forfeit later during the year on “Sick-
Sundays”
Family responsibility leave

You are entitled to 4 days’ family responsibility leave per annum due to illness or death
of an immediate family member. Absence due to humane reasons will ONLY be granted
with the permission of the lecturer and relevant motivation and information should be
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provided. Please take note that even though you have family responsibility leave
you still need to work the hours you forfeit later during the year on “Sick-
Sundays
Clinical arrangements
Practical instruments
Practical instruments will be available on eFundi.
Signing off practical procedures

It is your responsibility to be well prepared when you want to sign off a practical
procedure. You must make an appointment with the clinical preceptor, clinical
accompanist or lecturer when you want to sign off your practical procedure. You should
be fully prepared and have the relevant instrument and document ready when your
evaluator arrives. If you are not well prepared, your assessment opportunity will not be
postponed.
Instruction and guidance

Instruction and guidance to master the skills required in this module will be provided
during scheduled lecture sessions in January and during your practice shifts in the
hospitals. You will also be visited by a clinical preceptor during your practical shifts in
the hospital. These visits will also take place on a scheduled basis and you will be
expected to prepare and perform practical procedures (mandatory) that were
demonstrated during the January sessions.
Clinical skills
1. A list of the clinical skills required to successfully complete this module will be
posted on eFundi and should be filed in your Practical Portfolio under the tab
PRACTICAL PROGRESS PORTFOLIO.
2. After each practical skill demonstration, it is your responsibility to practice and
master the relevant skill. Should you experience any problems please contact the
clinical preceptor/lecturer for additional assistance.
3. Once you have mastered the skill, please arrange an assessment with your
clinical preceptor, peers or sister-in-charge (which ever applies). A copy of the
completed procedure where you were found competent should be signed filed
under the tab INSTRUMENTS, a signature on your practical register is required.
4. The successful completion of the skills listed on your practical register has to be
completed on the 31st of May. Your clinical preceptor will review your progress
during the March-April and June/July recess and provide feedback.
Practical portfolio
Your practical portfolio is a collection of evidence that you prepare to demonstrate
mastery, comprehension, application, and synthesis of your clinical skills. To be useful
as an assessment of your learning, the practical portfolio should contain the following:
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 Completed practical register
 Formative practical assessments
 Preparation for patient presentation
 Informal procedures
 Peer evaluations
Patient study
You will be expected to complete a patient study (individually) on any adult patient that
you looked after. You will make use of the patient study instrument that will be provided
to you. All patient studies need to be handed in September.
Practical register
This register serves as proof that you successfully completed the clinical skills required
in this module and that you comply with the requirements set by SANC. This is a legal
document and, has to be completed in black ink. Any changes made on the register
have to be noted by the lecturer or clinical preceptor. Please complete your register as
soon as you have mastered a skill. Your clinical preceptor will review your progress on
a monthly basis. A copy of the instrument used in each of the assessments must be
included under the tab INSTRUMENTS. The completed register must be submitted by
the 31st of May for summative assessment.
Assessments
Formative assessment
Formative assessments will be done on a continual basis during the course of the year.
The lecturer and clinical preceptor will conduct assessments based on the practical
register that can be found under the tab PRACTICAL PROGRESS PORTFOLIO.
Please note that in accordance with the general academic rules of the North-West
University you need proof of a participation mark of 50% to gain entry to the summative
assessment that will be conducted in October. Proof of participation is obtained in the
following manner:
Portfolio 30%
Patient study 20%
OSCE 50%
Total 100%
SUMMATIVE ASSESSMENT
Your summative assessment will be conducted in the clinical practice setting. You need
to have completed at least 80% of your required clinical practice hours to obtain entry
to the summative assessment. Proof of competence or a mark of 50% is required to
successfully complete this module. Final proof of competence is calculated as follows:
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Portfolio of evidence 50%
Proof of examination 50%
Final result 100%
ASSESSMENT SCALE
The assessment scale applies to all the instruments used in this module, and it is
important that you familiarise yourself with the scale before your first assessment. The
scale will be uploaded on the eFundi platform with the assessment instruments. You
must master the majority (50%) of the outcome criteria to master the clinical skill and
be declared competent. Outcome criteria marked with an asterisk (* A, B, C), is
considered a critical point, and is an aspect of a procedure which could severely
jeopardise patient safety or result in patient death. Information on the clinical skill,
outcomes, outcome criteria and critical points will be attached to each of the
instruments that are available on the eFundi platform for NSMP 321.
STUDENTS WITH LEARNING DIFFICULTIES AND DISABILITIES

Arrangements can be made for any student who needs help with learning strategies
and methods to perform better in their studies. The North-West University is also
equipped with the appropriate criteria for any student with a particular disability who
needs support. If you know of a student who is struggling in this way or if you yourself
feel that you need help in this regard, please contact the lecturer directly or address to
the subject chair to report the problem in question.
The Unit for Students with Disabilities (USWD) supports students to enable him/her to
reach their optimal potential in a culture of learning. Disabilities include physical l or
learning impairment as well as other temporary conditions. Feel free to contact them.
Potchefstroom Campus: The” Ingrypsentrum”, Building E14, Room G15.
Enquiries: 018 299 4431.
Mahikeng Campus: Protection services 018 389 2277 / 2167 / Nursing building
G07 block A13
WARNING AGAINST PLAGIARISM

ASSIGNMENTS ARE INDIVIDUAL TASKS AND NOT GROUP ACTIVITIES.
(UNLESS EXPLICITLY INDICATED AS GROUP ACTIVITIES)
Copying of text from other learners or from other sources (for instance the study guide,
prescribed material or directly from the internet) is not allowed – only brief quotations
are allowed and then only if indicated as such.
You should reformulate existing text and use your own words to explain what you
have read. It is not acceptable to retype existing text and just acknowledge the source
in a footnote – you should be able to relate the idea or concept, without repeating the
original author to the letter.
The aim of the assignments is not the reproduction of existing material, but to ascertain
whether you have the ability to integrate existing texts, add your own interpretation
and/or critique of the texts and offer a creative solution to existing problems.
Be warned: students who submit copied text will obtain a mark of zero for the
assignment and disciplinary steps may be taken by the Faculty and/or
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University. It is also unacceptable to do somebody else’s work, to lend your work
to them or to make your work available to them to copy – be careful and do not
make your work available to anyone!
For more information visit the NWU link for plagiarism.
Vir meer inligting besoek die NWU-skakel vir plagiaat.
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NSMP 321 PROCEDURE LIST
Student name and surname:
Student number:
PROCEDURES SIMLAB DEMONSTRATIONS

Signed by
Date Patient Name Formal Procedures
Lecturer/Preceptor
1. SIMLAB DEMONSTRATION Neurological assessment of an adult
2. SIMLAB DEMONSTRATION Vacuum drain maintenance
3. SIMLAB DEMONSTRATION Vacuum drain removal
4. SIMLAB DEMONSTRATION Assessment of the skin
5. SIMLAB DEMONSTRATION Patient presentation
Signed by
Date Patient Name Informal Procedures
Lecturer/Preceptor
1. SIMLAB DEMONSTRATION Changing of TPN
FORMAL PROCEDURES:
LECTURER/PRECEPTOR/FACILITATOR EVALUATIONS
Signed by Lecturer/
Date Patient Name Procedures Hospital Ward
Preceptor/Facilitator
1. Neurological assessment of an adult
2. Vacuum drainage maintenance
3. Vacuum drainage removal
4. Assessment of the skin
5. Patient case study
STUDY UNITS
STUDY UNIT 1: THE NEUROLOGICAL SYSTEM
Study time
You should use approximately 10 hours to complete this study section successfully
1.1 Neurological assessment of an adult

Learning outcomes
At the end of this study section, you should be able to:
 Understand the completion and interpretation of a Glasgow Coma Scale
 Know the indications for performing a neurological assessment on an adult patient
 Demonstrate competency in performing and interpreting the neurological history and examination
in an adult patient
Study material
Hinkle, J.C. & Cheever, K.H. 2018. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing. 13th
Edition. New York: Lippincott.
Mogotlane et al., 2018. Juta's Complete Textbook of Medical Surgical Nursing. 2nd ed. Juta.
Mulder et al., 2020. Practical guide for general nursing science. 2nd Edition. Pearson: South Africa
Viljoen, M.J. & Sibiya, N. 2009. History Taking and Physical Examination. 2nd Edition. Cape Town: Pearson.
Procedure Manual provided on eFundi
Extra study material on eFundi
NEUROLOGICAL ASSESSMENT OF THE ADULT PATIENT
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Outcome:
After completion of the practical programme, the student should be able to perform
a perform a neurological assessment on an adult patient in a competent manner
Assessment scale:
The student should familiarise him/herself with the following scale prior to the
assessment
0 1 2 3
Not done Done, incorrectly Done correctly Done correctly with a
without provision of a rational for actions
rational for actions
 Unable to  Conduct  Displays some  Displays initiative
function assessment initiative and and creativity.
independently criteria but creativity  Acts
 Does not possess incorrectly  Acts independently in
scientifically based  Forgot some independently in an ethically
knowledge or assessment an ethically responsible
skills. criteria but responsible manner.
 Has not mastered remember when manner.  Possesses above
set skills the preceptor  Possess average average
probe student or scientifically based scientifically based
give a hint knowledge. knowledge.
 Integrates theory  Integrates theory
and practice and practice
moderately outstandingly
You must obtain 50% of the outcome criteria to master the clinical skill and be declared
competent.
Outcome criteria marked with an “A”, “B” or “C is considered a critical point. A critical point is any
aspect of a procedure which could severely jeopardise patient safety or result in patient death.
A = 25%
B = 15%
C = 5%
DEFINING A NEUROLOGICAL ASSESSMENT:
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It is a complete and thorough evaluation of a person's nervous system using the Glasgow Coma Scale. The
Glasgow Coma Scale (GCS) is a valuable tool for recording the conscious state of a person and is based on
three patient responses: Eye opening, motor, and verbal response. The total score will range from 3
(coma) to 15 (fully conscious, alert and oriented). A score of 8 or lower usually indicates coma (CDC, 2013).
INDICATIONS FOR THE PROCEDURE:

A neurological assessment of a patient is indicated in the following instances:
 A routine physical examination
 Trauma to head, neck, or spine
 To follow progression of disease (Increased intracranial pressure, meningitis etc)
 Slurred speech
 Seizures
 Sudden confusion
 Change in balance and coordination
 Muscle weakness
POSSIBLE CONTRA-INDICATIONS:
 Active resuscitation
MEDICO-LEGAL RISKS INVOLVED:
 Misdiagnosing due to poor examination skills
EQUIPMENT:
 Small beam torch
 Long, hard object e.g., pen
 Protective gear, where indicated
 Neurological assessment chart with Glasgow Coma Scale
PROCEDURE: NEUROLOGICAL ASSESSMENT OF THE ADULT PATIENT
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ACTION RATIONAL
PSYCHOMOTOR COMPONENT
ASSESSMENT
1.  Identify the patient  Verification of the patient’s identity ensures
that the correct procedure is being done on the
correct patient
2.  Introduce yourself to the patient and  To alleviate anxiety and fear that might be
explain the procedure to be done (utilizing experienced by patient and.
easy terms and not medical terms)  To facilitate cooperation during the procedure
3.  Obtain verbal consent from the patient  Verbal or written consent is a legal
requirement for all procedures
4.  Wash your hands socially  To prevent the transmission of micro-
organisms (a universal precaution)
5. Assess the following in the patient’s file:
a.  Medical / Surgical history  Might provide information on the patient’s
neurological status
b.  Check the patient’s prescription chart  Provides information regarding possible
medications that might influence the outcome
of a neurological assessment
c.  Evaluate patients` vital signs  Increased BP and pulse could indicate
increased intracranial pressure
6. Assess the patient for the following
a.  Assess patient’s basic needs e.g.  To decrease any discomfort and possible
experience of pain or the need to use a disturbances during the procedure
bedpan/urinal
PLANNING
1.  Gather all equipment as indicated  For effective time management
2. Prepare environment:  Privacy for client
 Privacy  Neurologically compromised patient, nurse
 Comfort between cot sides to prevent injury
 Safety  Dark and quiet room to decrease stimuli to
 Darkened and quiet room an already altered neurological system,
also to enable accurate implementation of
the assessment
IMPLEMENTATION
1.  Wash hands and don protective gear  To reduce the transmission of micro-organisms
2.  Assess the patient’s neurological status  (The GCS is the most reliable coma scale
according to the Glasgow Coma Scale currently in use. It provides a means to rate a
patient’s level of consciousness) Also see
Appendix A for the GCS as seen in clinical
facilities
 Always start with the least noxious  This is to prevent inappropriate discomfort for
stimulus by addressing the patient by the the patient
name
 Introduce a tactile stimulus if there is no  Each stimulatory step in the GCS assumes that
response from the patient by tapping the the previous stimulus was not successful in
patient gently on his shoulder evoking a response
a. Assess patient’s eye opening  Eye opening is assessed to evaluate arousal, in
other words whether the patient is aware of
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ACTION RATIONAL
his environment
- Assess spontaneous eye opening by  If patient open his eyes spontaneously the
approaching the patient’s bedside and patient will score a 4 on the GCS
observing the patient
- Assess eye opening to speech by  If patient opens his eyes when asked in a loud
calling the patient by name and ask voice the patient will score a 3 on the GCS
patient to open his/her eyes. Do not
touch the patient at this stage
- Assess eye opening to pain by applying  If patient did not open his/her eyes to previous
a pain stimulus stimuli, only now pain stimuli may be applied
by pressing down on the patients’ nail bed with
a pen. If patient open his/her eyes to pain
stimuli the patient will score a 2 on the GCS
- Assess eye opening for no response  If the patient did not open his eyes to pain
after the application of pain stimulus stimuli the patient will score a 1 on the GCS
 The patients verbal response assess the central
b. Assess patient’s verbal response nervous system function within the cerebral
cortex
- Assess for orientation to person, place  If the patient can tell the examiner who he/she
and time is, where he/she is and the month and year,
the patient will score a 5 on the GCS
- Assess for confusion  If the patient seems confused or disorientated,
not knowing his/her name, where he/she is or
the month and year, the patient will score a 4
on the GCS
- Assess for inappropriate words  If the patient talks to the examiner, can
understand him/her but makes no sense
because the words are disorganised and
inappropriate the patient will score a 3 on the
GCS
- Assess for incomprehensible sounds  If the patient makes sounds that is not
understandable, not recognizable words, the
patient will score a 2 on the GCS
- Assess for no response  If the patient makes no noise, he/she will score
a 1 on the GCS
 Re-orientate the confused patient after  Re-orientation will reinforce reality
the patients’ verbal response was assessed
 Assessing the motor response will indicate that

the sensory function is intact and that the
c. Assess patient’s motor response
motor function from the cortex to the muscle is
present
- Assess whether patient can obey  If the patient can follow a simple command the
commands by giving the patient a simple patient will score a 6 on the GCS
instruction e.g., lift your arm
- Assess for localizing pain with application  If the patient tries to remove the pain stimulus
of pain stimulus e.g., lay a pen across the through purposeful movement of a limb
patient’s fingernail bed and press firmly towards the pain stimulus e.g., attempts to
push the examiners hand away when the
v
ACTION RATIONAL
stimulus is applied, the patient will score a 5 on
the GCS
- Assess for withdraw from pain with  If the patient pulls away from the pain stimulus
application of pain stimulus but no attempt to remove the pain stimulus,
- Assess for abnormal flexion with  If patient flexes body inappropriately
application of pain stimulus (decorticate posture) to pain e.g.
- Extreme wrist flexion
- Abduction of the upper arm and
- Flexion of the fingers over the thumb
- Assess for abnormal extension with  If the patient’s body becomes rigid in an
application of pain stimulus extended position (decerebrate posture) with
extension at the elbow usually adducts and
rotates internally at the shoulder, the patient
will score a 2 on the GCS
- Assess for no response with application of  If the patients have no response to the pain
pain stimulus stimulus, the patient will score a 1 on the GCS
3. Assess patients’ limb movement /  For early detection of possible neurological
strength deficits
- Test all four limbs and follow the same  Testing all four limbs will ensure accurate and
procedure as for the GCS complete neurological assessment because an
injury to a limb may lead to the inaccurate
assessment of neurological function
- Differentiate between voluntary and  Voluntary activity implies that higher brain
involuntary movement / activity centre activity is present and involuntary
movement may be an indication of spinal cord
reflexes
- Assess whether the patient has normal  Instructing the patient to release your fingers
power, mild weakness or severe on command will help to distinguish between
weakness of his/her arms by asking the obeying command from a co-incidental grip.
patient to grip the 2nd and 3rd fingers of  The patient will either have normal power, less
your hands and then instruct the patient power (mild weakness) or little power (severe
to release your fingers weakness) of his arms
- Assess whether the patient has normal  The patient will either have normal power, less
power, mild weakness or severe power (mild weakness) or little power (severe
weakness of his/her legs by asking the weakness) of his legs
patient to push his/her feet against your
hands
- Assess for spastic flexion of all limbs by  Spastic flexion will only be present after pain
applying pain stimuli stimulus was applied. Please see description of
spastic flexion under assessment of motor
response
- Assess for extension of all limbs by  Extension will only be present after pain
applying pain stimuli stimulus was applied. Please see description of
extension under assessment of motor response
- Assess for no response of all limbs  If no response is present in all limbs patient will
not move any limbs during or after pain
vi
ACTION RATIONAL
stimulus
4.  Increase Intracranial pressure can displace the
Assess the patient’s pupil reaction brain against the oculomotor or optic nerve,
producing pupillary changes
- Ensure that the environment is darkened  The pupil may be constricted due to light in the
room and inaccurate assessment can be made
- Open the patient’s eyelids with one hand  To ensure that the patient does not close his
eyes involuntary with the light shining in
his/her eyes
- Shine the light in one eye at a time and  The pupils should constrict briskly (fast) to
observe the pupil size, equalness, shape light, both should be round in shape and
and response to light similar in size
- Keeping both eyes open, compare the  Both pupils should be similar in size, shape and
sizes of the pupils, without shining the reaction
light
5.  Remove gloves (if used) and disinfect 
To prevent the transmission of micro-
hands organisms
6.  Make patient comfortable  Patient has a basic right to optimum comfort
7.  Ensure patient safety by placing the bell Patients need to be able to call for assistance
within easy reach STAT in case of abnormalities
 Patient always has the right to be in a safe
environment
8.  Report any abnormalities and action  To reduce medico-legal risks, the nursing
student always need to report
DOCUMENTATION
1. Document the following
 Glasgow Coma Scale as a numerical value  Accurate documentation is essential for base
or in a graph or both line data and future comparison.
 Movement of the four limbs (forms part of  If not written it was not done
the GCS document)
 Pupil size, shape and reaction to light
(forms part of the GCS document)
 Procedure that was done in the progress
report
APPENDIX A – GLASGOW COMA SCALE
vii
PEER EVALUATION
viii
INSTRUMENT: NEUROLOGICAL ASSESSMENT OF THE ADULT PATIENT
DATE:
NAME OF STUDENT:
STUDENT NUMBER
STUDENT SIGNATURE
EVALUATOR
RESULT IN PERCENTAGE
OUTCOME CRITERIA 0 1 2 3 REMARKS

COGNITIVE COMPONENT
1. Define the concept “neurological assessment”
2. Provide 2 indications for the procedure
3. Discuss the history and management of the patient
4. Discuss action in case of abnormalities
ASSESSMENT
1. Identified patient
2. Introduced self, and procedure explained
3. Obtained verbal consent
4. Washed hands socially
5. Patient’s file assessed for the following:
a.  Medical / Surgical history
b.  Prescription chart for neurological medications
and specific orders
c.  Assessed and interprets vital signs
6. Patient assessed for:
a.  Basic needs
PLANNING
1. All needed equipment gathered
2. Environment prepared
IMPLEMENTATION
1. Hands washed socially and protective gear used if
needed
2. Assessed the patient’s neurological status according to the Glasgow Coma Scale
 Started with the least noxious stimulus,
progressing to more noxious stimulus as
indicated
 Applied one stimulus at a time
a. Correctly assessed eye opening C
b. Correctly assessed verbal response C
 Re-orientated the patient where needed
c. Correctly assessed motor response C
 Used acceptable pain stimulus where needed
3. Limb movement:
 Correctly assessed limb movement of all four
limbs
 Correctly assessed muscle strength in all four
ix
limbs
4. Correctly assessed pupils for:
 reaction to light
 Pupil shape
 Pupil size
 Equality of pupils
5.  Gloves removed and hands disinfected
6.  Patient made comfortable
7.  Safety ensured by placing bell within reach
8.  Actions and abnormalities reported
DOCUMENTATION
1. The following was documented
 Date and time
 Neurological observations completed correctly
in die relevant spaces for the GCS, limb
movement and strength and pupil size, shape,
reaction and equality
 Procedure done, abnormalities found, and
actions taken in the progress report
AFFECTIVE COMPONENT
1. Student has adequate verbal and non-verbal
communication skills
 Professional in behaviour
 Friendly and approachable
 Reassuring patient
CALCULATION OF MARK: Total marks on Evaluation scale
____ X 100 = %
= 1
(Subtract N/A from total)
REMARKS
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
____________________________
PROCEDURE SIGNED OFF BY PROFESSIONAL NURSE
x
NEUROLOGICAL ASSESSMENT OF AN ADULT PATIENT
YES NO
1. Identified the patient
2. Prepare the environment (eg dim lights,noise level, privacy etc.)
3. Observe and describe eye opening response
4. Observe and describe best verbal response
5. Observe and describe best motor repsonse
6. Interpret patients Glascow Coma Scale
7. Assess and interpret patients` other neurological observations:
 Pupil reaction
 Vital signs
8. Document and report findings
Signature of RN: ___________________________
Signature of student: _________________________
Remarks: (student competent/not yet competent/needs guidance)

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________
FORMAL ASSESSMENT
xi
INSTRUMENT: NEUROLOGICAL ASSESSMENT OF THE ADULT PATIENT
DATE:
NAME OF STUDENT:
STUDENT NUMBER
STUDENT SIGNATURE
EVALUATOR
RESULT IN PERCENTAGE

COGNITIVE COMPONENT
1. Define the concept “neurological assessment”
2. Provide 2 indications for the procedure
3. Discuss the history and management of the patient
4. Discuss action in case of abnormalities
ASSESSMENT
5. Patient’s file assessed for the following:
a.  Medical / Surgical history
b.  Prescription chart for neurological
medications and specific orders
c.  Assessed and interprets vital signs
6. Patient assessed for:
a.  Basic needs
PLANNING
2. Environment prepared
IMPLEMENTATION
1. Hands washed socially and protective gear used if
needed
2. Assessed the patient’s neurological status according to the Glasgow Coma Scale
 Started with the least noxious stimulus,
progressing to more noxious stimulus as
indicated
 Applied one stimulus at a time
a. Correctly assessed eye opening C
b. Correctly assessed verbal response C
 Re-orientated the patient where needed
c. Correctly assessed motor response C
 Used acceptable pain stimulus where needed
3. Limb movement:
 Correctly assessed limb movement of all four
limbs
xii
 Correctly assessed muscle strength in all four
limbs
4. Correctly assessed pupils for:
 reaction to light
 Pupil shape
 Pupil size
 Equality of pupils
5.  Gloves removed and hands disinfected
6.  Patient made comfortable
7.  Safety ensured by placing bell within reach
8.  Actions and abnormalities reported
DOCUMENTATION
1. The following was documented
 Date and time
 Neurological observations completed correctly
in die relevant spaces for the GCS, limb
movement and strength and pupil size, shape,
reaction and equality
 Procedure done, abnormalities found, and
actions taken in the progress report
AFFECTIVE COMPONENT
____ X 100 = %
= 1
REMARKS
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
____________________________
xiii
1.1.1 INFORMAL PROCEDURES (NEUROLOGICAL SYSTEM)
NEUROLOGICAL CLINICAL SKILLS
PROCEDURE DATE WARD/UNIT SIGNATURE: PRECEPTOR/RN/DOCTOR

Observe a patient going for the following diagnostic 1.
tests:
 CT Brain 2.
 Electroencephalogram (EEG)
3.
 MRI scan
Assist a doctor during lumbar puncture
Attend an academic round
Monitors a patient diagnosed with increased

intracranial pressure on ICP monitor
1.
Develop a nursing care plan for a patient with
neurological disorders 2.
NURSING CARE PLANS FOR NEUROLOGICAL PATIENTS
CARE PLAN 1
Patient name: __________________________
Medical diagnosis: __________________________
Nursing diagnosis:
1.
2.
Nursing diagnosis Intervention Rationale
i
CARE PLAN 2
Patient name: __________________________
Nursing diagnosis:
1.
2.
ii
STUDY UNIT 2: THE RENAL SYSTEM
Study time
2.1Management of a patient with renal failure

Learning outcomes
 Understand the management of a renal patient through haemodialysis and peritoneal dialysis
 Know the indications for renal dialysis
 Demonstrate competency in completion, monitoring and interpretation of a patients` fluid balance

chart
Study material
iii
2.1 INFORMAL PROCEDURES (RENAL SYSTEM)
RENAL CLINICAL SKILLS
PROCEDURE DATE WARD/UNIT SIGNATURE: PRECEPTOR/RN/DOCTOR
2.1.1 Renal visit
1.
2.1.2 Balances fluid chart
2.
1.
2.1.3 Formulates nursing care plan for renal patient
2.
NURSING CARE PLANS FOR RENAL PATIENTS
CARE PLAN 1
Patient name: __________________________
Nursing diagnosis:
1.
2.
2
CARE PLAN 2
Patient name: _________________________
Medical diagnosis: _________________________
Nursing diagnosis:
1.
2.
3
4
SCENARIO (SIMLAB)
Mr S is admitted in the renal unit with chronic renal failure. Patient is on strict intake and
output monitoring. The patient is assigned to you, and you need to monitor their intake and
output.
Mr S had breakfast and had a glass of juice (170 ml) at 08h00, had yoghurt (125 ml) and a bowl
of porridge (250mls). For lunch Mrs S didn`t have an appetite and had a cup of tea (150 ml).
Mr S IV fluids have been on 100mls of 9% normal saline. After the ward round at 10h00 IV fluids
are reduced from 100mls to 80 ml. He had 100 ml of paracetamol IV at 14h00.
Mr S weights 70kg and had a urine output as follows:
08h00 – 35 ml
09h00 – 50 ml
10h00 – 30 ml
He has a portovac drain, that drained 25 ml serous fluid at 14h00 and 30 ml at 18h00. He has
also been complaining of nausea and vomited 250 ml of green vomitus.
Calculate Mr S input and output for the end of day shift.
5
STUDY UNIT 3: THE GASTROINSTESTINAL SYSTEM
Study time
3.1Changing of Total Parental Nutrition
Learning outcomes
 Know the indications TPN administration
 Demonstrate competency in changing a patient total parental nutrition
Study material
Viljoen, M.J. & Sibiya, N. 2009. History Taking and Physical Examination. 2nd Edition. Cape Town:
Pearson.
6
ADMINISTRATION OF TOTAL PARENTERAL NUTRITION (TPN)
Outcome:
After completion of the practical programme, the student should be able to
administer Total Parenteral Nutrition in a safe and competent manner
Assessment scale:
assessment
0 1 2 3
competent.
A = 25%
B = 15%
C = 5%
7
DEFINITION:
Total parenteral nutrition (TPN) is the continuous intravenous administration of varying combinations of
glucose, lipids, amino acids, electrolytes, vitamins, and trace elements. TPN is designed to be
nutritionally complete to meet the total nutritional needs of the patient. TPN is only provided
intravenously preferably through a central venous pressure line. (Altman et al. 2010:1118; Mulder et al.
2020:1014)
INDICATIONS FOR TOTAL PARENTERAL NUTRITION:

To promote anabolism, supplying nutritional support and to limit catabolism to the minimum in the
following patients:
• Where the gastro-intestinal tract is not able to absorb nutrients e.g., ulcerative colitis, burns
metastatic carcinoma, acute renal and hepatic failure
• Where oral feeds have been discontinued for a period of longer than five days
• A patient who is unable to tolerate oral or enteral nutrition by day three – 5 post operatively
• Patients with pre-existing protein-energy malnutrition e.g., prolonged paralytic ileus, diarrhoea, and
anorexia nervosa
• Patients who receive high dosages of chemotherapy
• Patients with complete bowel obstruction
• Repetitive surgery due to trauma (Mulder et al. 2020:1015)
• A functional gut
• The need for emergency therapy
• Patient’s refusal
• When the risks related to TPN exceeds the potential benefits
• An inability to obtain venous access (Mulder et al. 2020:1015-1016)

• Incorrect patient identification
• Incorrect Total parenteral nutrition provided
• Injury due to poor technique, e.g., tissue damage, infection
• Not identifying and reporting abnormalities
• Failure to provide health education
COMPLICATIONS ASSOCIATED WITH TOTAL PARENTERAL NUTRITION:

• Central venous pressure line sepsis
• Electrolyte abnormalities
8
• Rebound hypoglycaemia when TPN is discontinued
• Hyperglycaemia with over feeding
• Fat embolism when filter is not used
• Phlebitis and infiltration when provided peripherally etc
EQUIPMENT/STAFF:
• Prescription chart
• TPN solution
• Dark bag to cover TPN solution during administration (TPN is light sensitive)
• Sterile towel / drape
• Disposable sterile gloves
• Dressing pack
• TPN IV line with a filter in situ
• Disposable apron and cap
• Chlorhexidine in alcohol solution
• Infusion pump
9
PROCEDURE: ADMINISTRATION OF TOTAL PARENTERAL NUTRITION (TPN)
ACTION RATIONAL
ASSESSMENT
1.  Identify the patient  Verification of the patient’s identity ensures
that the correct procedure is being done on
the correct patient
explain the procedure to be done (utilizing experienced by patient
easy terms and not medical terms)  To facilitate cooperation during the
procedure
3.  Obtain verbal consent from the patient  Verbal or written consent is a legal
requirement for all procedures
5. Assess the following in the patient’s file:
a.  Medical / Surgical history  This will provide the indication for the
administration of TPN e.g., paralytic ileus
post-surgery
b. Prescription chart for the following:  This will ensure that the correct patient is
provided with the correct TPN and the
 Patient’s name
correct amount per hour thus preventing
 Type of TPN to be provided
any medico-legal risks
 Flow rate of administrating TPN
c.  Check whether patient has any history of  To prevent any anaphylactic reactions and
food allergies e.g., eggs possible lethal consequences in patients
who receive lipid emulsions.
d.  Evaluate the patient’s nursing care plan  The nursing care plan will provide you with
nursing diagnosis, interactions, and specific
indications for the administration TPN
e.  Confirm laboratory reports on blood  TPN can alter glucose levels and electrolyte
glucose, urea and electrolytes levels.
 Laboratory results might also indicate the
reason for the specific TPN solution
provided or e.g., a patient with renal failure
and high serum potassium levels will receive
a renal TPN bag with little or no potassium
in the solution
f.  Vital data  TPN can produce serious complications such
as metabolic changes, fluid and electrolyte
imbalance, line sepsis etc. It is therefore
critical that the nurse know the patient’s
baseline data to be able to monitor for
complications
10
ACTION RATIONAL
6. Assess the patient for the following:
a.  Knowledge regarding the administration of  Patient has the right to participate in
TPN decision making regarding treatment
b.  Infusion site for:  TPN may only be given directly into a vein
 infiltration, for safe administration.\
 leakage or  Clinical manifestations of
 pain infiltration/phlebitis might include swelling,
(This is applicable when Peripheral TPN is redness, pain or burning, blanching and
provided into a peripheral vein) coldness (infiltration) or warmness
(phlebitis)
PLANNING
1.  Remove the prescribed TPN solution from  The infusion of cold solutions can cause
the refrigerator one hour before changing pain, hypothermia, venous spasm and
the bag or commencing the TPN constriction
2.  Check the label on the TPN bag for the TPN is expensive therefor the correct bag needs
patients details and patient number and to be administered to the correct patient
the TPN code before opening the bag and according to medical diagnosis, laboratory
checked with RN values etc
 Administration of the wrong bag of TPN can
lead to severe electrolyte imbalances and
other fluid related complications because
each bag is prepared according to patients
needs
3.  Confirm the expiry date of the solution Due to the risk of infection, expired TPN should
not be used.
The hang time of TPN should not exceed 24
hours. After opening of the TPN bag,
sterility is only guaranteed for 24 hours by
the manufacturers. Although the remaining
amount of the solution is supposed to be
discarded after 24 hours, many facilities
increase the hanging time for the bag to be
completed.
4.  Gather all equipment and stock needed  For effective time management
for the procedure
IMPLEMENTATION
2.  Put on protective gear, cap and apron  To prevent the transmission of any micro-
organisms onto the sterile field to be
worked on
3.  Open the large sterile cloth/drape onto a  To provide a sterile environment for TPN
clean trolley in an aseptic manner solution and accessories needed for the
procedure
4. Cut open the cover bag of the TPN solution  To prevent the transmission of micro-
and throw the TPN bag onto the sterile organisms
field without contaminating the sterility
thereof
5. Open all sterile accessories onto the opened  To ensure the sterility of all stock used on
11
ACTION RATIONAL
sterile cloth/drape (This includes content the trolley in an attempt to minimise the
of a dressing tray, TPN administration set chances of any infection.
and filter (if separate from administration
set
6. Spray the bottom of the empty dressing tray  To maintain sterility of the environment
with chlorhexidine in alcohol, when dry put on
the furthest end of the sterile environment.
7.  Pour the chlorhexidine in alcohol into the  The chlorhexidine will be used as a cleaning
empty dressing tray solution prior to connecting the TPN to the
allocated CVP port
8. Excuse yourself and wash hands aseptically  To prevent transmission of micro-organisms
either with water and Bioscrub or with
alcohol hand rub
9.  Put on sterile gloves (dressing tray  Without sterile gloves sterile environment
content) and organise the sterile field may not be touched
10  Inspect the TPN solution for cracking,  The TPN solution should be uniform
. leaking and discoloration and a cream without areas of fat separation.
layer of separation  If cracking and leaking is present it can
predispose patient to a intravascular
bacterial infection alias sepsis
11  Using aseptic technique, attach the tubing  Reduces the transmission of
. to the TPN bag and prime the line while microorganisms. Priming prevents air
working on the sterile trolley embolism
12  Create a sterile environment at the CVP  To maintain sterility throughout the
. port to be used for TPN administration procedure and to prevent the entry of
microorganisms into the patient’s vascular
system
13  Use the chlorhexidine in alcohol with the  To ensure sterility of the connection area
. gauzes provided from the dressing pack prior to connecting the sterile TPN
and wash the port clean prior to administration set
connecting the TPN administration set
14  Wait until dry and connect the TPN  Alcohol is only effective after use when it
. administration set to the allocated CVP has dried
port
15  Remove sterile gloves  As soon as the TPN administration set is
. connected to the CVP port sterile gloves is
not needed anymore and you do not have a
contaminated trolley therefor no gloves are
needed anymore
16  Hang the TPN solution on the IV Pole and  TPN flow rate must be regulated through an
. prime the tubing into the allocated IV IV administration pump
administration pump (The TPN bag was
still lying on the sterile trolley up to now)
17  Regulate the flow rate based on the  To ensure that the require nutritional and
. prescription provided by either the metabolic needs are achieved
attending doctor or the dietitian
12
ACTION RATIONAL
18  Discard all medical waste appropriately  Standard precaution to prevent the
. transmission of microorganisms
19  Wash your hands socially  To prevent transmission of micro-organisms
.
20  Report any abnormalities and action  To reduce medico-legal risks, the nursing
. student need to report at all times
DOCUMENTATION
1. Document the following in the progress report
 Date, time and procedure done  If not written, not done. For complete and
 Type of TPN and flow rate per minute accurate documentation
 Abnormalities and actions taken
13
PEER ASSESSMENT
INSTRUMENT: ADMINISTRATION OF TOTAL PARENTERAL NUTRITION (TPN)
DATE:
NAME OF STUDENT:
STUDENT NUMBER
STUDENT SIGNATURE
EVALUATOR
RESULT IN PERCENTAGE (%)

COGNITIVE COMPONENT
Provide the evaluator with the following:
1. Define the concept Total Parenteral Nutrition
2. Provide 3 indications for the administration of
TPN
3. Provide 3 complications of TPN administration
ASSESSMENT
5. Assessed the patients file for the following
a. Medical/surgical history
b. Prescription chart: A
 Patient’s name
 Type of TPN to be administered
 Flow rate of TPN
c. Checked for allergies
d. Patient care plan checked
e. Laboratory results
f. Vital data
6. Assessed the patient for the following
a. Knowledge regarding the nutrition provided
b. Infusion site for infiltration, leakage, or pain (if
peripheral TPN will be provided)
PLANNING
1. TPN solution removed from fridge 1 hour prior
to administration thereof
2. Patient’s details on TPN bag confirmed with RN
3. Expiry date checked A
4. All necessary equipment and stock gathered
IMPLEMENTATION
1. Hands washed socially
2. Protective gear used appropriately
3. Sterile field created on trolley with sterile drape
4. TPN solution opened and placed onto sterile
field without contaminating the bag
5. All sterile accessories opened onto sterile field
6. Empty dressing tray managed in the correct
i
manner
7. Chlorhexidine in alcohol poured into empty
dressing tray
8. Hands washed aseptically
9. Sterile gloves put on
10. TPN solution inspected for cracks, leaks and
discoloration
11. TPN administration set connected to the TPN
B
solution and primed correctly
12. Sterile field created at allocated CVP port
13. CVP port washed with chlorhexidine in alcohol
14. TPN administration set connected to CVP port in
an aseptic manner
15. Sterile gloves removed
16. TPN administration set placed correctly into IV
pump
17. Flow rate started as requested by attending
doctor
18. Medical waste disposed correctly
20. Abnormalities and actions reported
DOCUMENTATION
The following was documented in the progress report:
 Date, time, procedure done
 Type of TPN and flow rate per minute
 Abnormalities found and actions taken
AFFECTIVE COMPONENT
Student has adequate verbal and non-verbal
X 100 = %
= 1
REMARKS
ii
CHANGING OF TPN
YES NO
2. Checked prescription chart
3. Collect relevant equipment
4. Sterility mainted during change of TPN
5. Observe patients reaction to TPN
6. Document and report findings
Signature of RN: ___________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_________________________________________________________________________________
STUDY UNIT 4: THE REPRODUCTIVE SYSTEM
Study time
iii
4.1Maintenance and removal of a vacuum drainage device

Learning outcomes
 Describe a vacuum drainage device
 Differentiate between different types of vacuum drainage devices
 Name indications, contra indications and medico-legal risks associated with the procedure
 Demonstrate the maintenance and removal of a vacuum drainage device
Study material
MAINTENANCE OF A VACUUM DRAINAGE DEVICE

(PORTOVAC, BULB, J-VAC)
Outcome:
iv
Assessment scale:
assessment
0 1 2 3
competent.
A = 25%
B = 15%
C = 5%
DEFINITION:
A vacuum drainage device system is placed into vascular cavities where blood drainage is expected post-
surgery, e.g., abdominal and orthopaedic surgery. These drains consist of perforated tubing connected to a
portable vacuum unit. Compression of a spring-like device maintains the suction in the collection unit. The
v
surgeon will place one end of the drain in or near the area of surgery to be drained and the other end
passes through the skin via a separate incision. The drain will then be usually sutured in place (depending
on the surgeon). This area is seen as an additional surgical wound. When drainage accumulates in the
collection unit, the spring-like device will expand, and suction will be lost – requiring recompression. To be
emptied 4 – 12 hourly depending on drainage and surgeon’s/unit protocol (Evans-Smith, 2005:274).
 To ensure the patency of the drainage system

 To assess for the presence of excess drainage or bleeding or saturation of the wound dressing
 To assess whether drainage decreased to an acceptable amount for the drainage system to be removed
 Procedure done on wrong patient

 Infection due to contamination
 Devices not functioning properly will lead to hematoma formation
 Accidental removal of drain with wound still actively draining
 Failure to provide health education
 Incomplete or incorrect documentation
 Increased length of stay with added medical costs
EQUIPMENT / STAFF:
 Artery forceps
 Linen saver
 Unsterile gloves
 Kidney dish / Measuring jug
 Alcohol swab
 Paper towel
PROCEDURE: MAINTENANCE OF A VACUUM DRAINAGE DEVICE

ACTION RATIONAL
vi
ACTION RATIONAL
ASSESSMENT
1.  Identify the patient  Verification of the patient’s identity ensures that
the correct procedure is being done on the correct
patient
explain the procedure to be done experienced by patient and;
 to facilitate cooperation during the procedure
3.  Obtain verbal consent from the  Verbal or written consent is a legal requirement for
patient all procedures
4.  Wash your hands socially  To prevent the transmission of micro-organisms (a
universal precaution)
Assess the following in the patient’s file:
5.  Surgical history  Provide indication for drain insertion
 Confirming the area of drainage system insertion
site
6.  Check the patient’s prescription  For specific instructions regarding wound care and
chart removal of the drain
7.  Evaluate the patient’s nursing care  The nursing care plan will provide you with nursing
plan diagnosis, interventions and specific instruction on
how often drainage must be assessed, wound care,
etc.
8.  Check patient’s Fluid balance chart  To assess previous amount of drainage e.g.,
increase or decrease in drainage
 To assess if drain is still patent
Assess patient for the following:
9.  Physical and psychological ability to  Disorientation might lead to contamination and
participate spillage
10.  Assess patient’s basic needs e.g. the  To decrease any discomfort and possible
need to use a bedpan/urinal disturbances during the procedure
11. Assess current dressing for the following:  To provide information regarding active bleeding
 Drainage: colour & amount and infectious changes.
 Bleeding  Saturated dressings will indicate dressing change
 Clinical manifestations of infection
 Saturation of dressing
12. Assess the patency of the drainage  Blocked drainage systems might lead to hematoma
system e.g. formation at the surgical site.
- Suctioning is still maintained.  Free, untwisted and unkinked tubing promotes the
- Tubing must be free from twist drainage from the wound area
and kinks.
13.  Excuse yourself from patient,  Keeping patient informed regarding actions will
remove gloves and wash hands enhance cooperation
socially
PLANNING
2.  Provide patient with privacy where  Patient has a right to privacy at all times
needed  To prevent unnecessary exposure e.g., abdominal
drainage systems
IMPLEMENTATION
1.  Remove linen without exposing the  Medico-legal requirement to protect patient’s
patient unnecessary rights at all times
vii
ACTION RATIONAL
2.  Put on unsterile gloves  To protect yourself from contact with bodily fluids
of patients
3.  Place linen saver under drainage  Linen saver protects underlying surfaces
container
4.  Close the clamp of drainage system /  This will stop the suctioning pressure
use artery forceps to clamp drainage  Prevent the entry of air into the drainage system
system and surgical site
5.  Release the vacuum by opening the  The spout cap needs to be opened to be able to
spout cap of the drainage system empty the drainage system
6.  Tilt the drainage system into the  Allowing the total amount of drainage to be
measuring jug collected into the measuring jug
7.  Wipe the outside of the device with  When drainage is present at the outside of the
paper hand towel without touching device area, linen will be contaminated with
the inside of the spout area and drainage.
clean the spout and cap with an  Touching the inside of the spout area will
alcohol swab contaminate a sterile environment
(This is only done if there is visible  Cleaning with an alcohol swab will prevent
drainage spillage in these areas) contamination of the valve and reduces the risk for
microorganism transmission
8.  For Portovac: Create a vacuum by  Creating optimum vacuum in the drainage system
pressing down on the drainage will promote optimal drainage from wound area
system until all air is expelled and
replace the cap.
 For Bulb-drain: Squeeze drain with
your hand to expel air and close cap.
 For J-Vac systems: Press down to
release all air and replace cap but
also flip the lower part up to activate
the vacuum
9.  Unclamp drainage system or release  System need to be unclamped again for any
artery forceps and check patency of draining to take place.
drainage system again
10.  Carefully measure the drainage in  Drainage might consist of pus, fresh blood, old
the sluice. darker blood, serous fluid or even some tissue.
Take note of the:  This is important information needed for the
 Character attending surgeon to make decisions regarding the
 Colour and drainage system
 Amount of drainage
11.  Remove gloves and disinfect your  Universal precaution
hands
12.  Ensure that patient is comfortable  Comfort is a basic right of the patient
13.  Ensure patient safety by placing the  Patients need to be able to call for assistance STAT
bell within easy reach in case of abnormalities
 Patient has the right to be in a safe environment at
all times
14. Provide health education to the patient  To prevent medico-legal risks
regarding:
 Bleeding: to report immediately
 When drainage system is filled up: to
report immediately
viii
ACTION RATIONAL
 Not to pull on drainage system
 Not to open the cap or empty the
system
15.  Report any abnormalities and action  To reduce medico-legal risks, the nursing student
need to report at all times
EVALUATION
1.  Check that system is still patent and  To be able to ensure good drainage and prevention
suctioning every 2-4 hours of hematoma formation
depending on amount of drainage
DOCUMENTATION
Document the following on the FLUID BALANCE CHART:
1.  Amount measured under the  For complete and accurate documentation
correct column, at the correct regarding drainage
time space  Are usually calculated at the end of each shift.
Document the following in the PROGRESS REPORT:
2.  Date and time  For complete and accurate documentation.
 Procedure done  To compare type and amount of drainage with
 Amount of drainage future drainage.
 Type of drainage  NB! If not written, it is considered as not being
 Health education provided done
PEER EVALUATION
ix
INSTRUMENT: MAINTENANCE OF A VACUUM DRAINAGE DEVICE
DATE:
NAME OF STUDENT:
STUDENT NUMBER
STUDENT SIGNATURE
EVALUATOR

COGNITIVE COMPONENT
1. Indications (2) for maintaining a vacuum
drainage device
2. Possible medico-legal risks (2) involved
ASSESSMENT
1. Identified patient A
Patient’s file assessed for the following
5. Surgical history
6. Prescription chart for specific instructions B
7. Patient care plan
8. Fluid balance chart C
Patient assessed for:
9. Physical and psychological ability to participate
10. Basic needs
Current dressing assessed for:
11. Colour and amount of drainage
12. Bleeding
13. Clinical manifestations of infection
14. Saturation of current dressing
Patency of drainage system assessed for:
15.  Maintained suctioning
C
 Kinked or twisted tubing
16. Excused self, removed gloves, washed hands
PLANNING
2. Privacy provided
IMPLEMENTATION
1. Linen removed without unnecessary exposure
2. Unsterile gloves put on
3. Linen saver placed under drainage container
4. Drainage system clamped A
5. Vacuum released
6. Drainage system tilted correctly to empty into
measuring jug
7. Outside of device wiped with paper towel, (Only in case of
x
spout and cap cleaned with alcohol swab spillage)
8. Vacuum created again in the correct manner B
9. Drainage system unclamped and patency
A
ensured
10. Drainage measured accurately in the sluice for:
 Character
 colour
 amount
11. Gloves removed and hands disinfected
12. Patient made comfortable
13. Bell placed within easy reach
14. Health education provided as indicated
15. Abnormalities and actions reported to RN
EVALUATION
1. Drainage system checked for patency and
suctioning every 2-4 hours as needed
DOCUMENTATION
The following was documented:
1. Fluid balance chart:
C
 Correct time, correct amount
2. Progress report:
 Date and time,
 Procedure done,
 Amount and type of drainage,
 Health education provided
AFFECTIVE COMPONENT
____ X 100 = %
= 1
REMARKS
________________________________________________________________________________________
________________________________________________________________________________________
__________________________________________________________
xi
MAINTENACE OF A VACUUM DRAINAGE DEVICE
YES NO
2. Puts on unsterile gloves
3. Protect linen with linen saver
4. System clamped before opening
5. Device drained correctly and vacuum created
6. Clamp removed
7. System evaluated for patency
8. Drainage documented on fluid balance chart
9. Abnormalities reported to RN
Signature of RN: ___________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
___________________________________________________________________________________
FORMAL EVALUATION
INSTRUMENT: MAINTENANCE OF A VACUUM DRAINAGE DEVICE
xii
DATE:
NAME OF STUDENT:
STUDENT NUMBER
STUDENT SIGNATURE
EVALUATOR

COGNITIVE COMPONENT
1. Indications (2) for maintaining a vacuum
drainage device
ASSESSMENT
5. Surgical history
10. Basic needs
12. Bleeding
C
PLANNING
2. Privacy provided
IMPLEMENTATION
5. Vacuum released
measuring jug
7. Outside of device wiped with paper towel, (Only in case of
spout and cap cleaned with alcohol swab spillage)
8. Vacuum created again in the correct manner B
xiii
9. Drainage system unclamped and patency
A
ensured
 Character
 colour
 amount
EVALUATION
1. Drainage system checked for patency and
suctioning every 2-4 hours as needed
DOCUMENTATION
C
2. Progress report:
 Date and time,
 Procedure done,
AFFECTIVE COMPONENT
____ X 100 = %
= 1
REMARKS
________________________________________________________________________________________
________________________________________________________________________________________
__________________________________________________________
xiv
| Study unit 1
PROCEDURE: REMOVAL OF A VACUUM DRAINAGE DEVICE

(PORTOVAC, BULB, J-VAC)
Outcome:
Assessment scale:
assessment
0 1 2 3
competent.
A = 25%
B = 15%
C = 5%
1
Le1 | Study unit 1
DEFINITION:
A portovac drain is placed into vascular cavities where blood drainage is expected post-surgery, e.g.
abdominal and orthopaedic surgery. These drains consist of perforated tubing connected to a portable
vacuum unit. Compression of a spring-like device maintains the suction in the collection unit. The surgeon
will place one end of the drain in or near the area of surgery to be drained and the other end passes
through the skin via a separate incision. The drain will then be usually sutured in place (depending on the
surgeon). This area is seen as an additional surgical wound. When drainage accumulates in the collection
unit, the spring-like device will expand, and suction will be lost – requiring recompression. To be emptied 4
– 8 hourly depending on drainage and surgeon’s / unit protocol (Evans-Smith, 2005:274).

 Blocked drainage systems (on request of the attending doctor)
 When drainage is minimum (less than 50ml/24hours on written request by attending doctor).
 When active drainage is still present
 If not requested by the attending doctor in WRITING

 Procedure done on wrong patient
 Allergic reactions to cleaning solutions or dressing products
 Infection due to contamination
 Removal of drain with wound still actively draining
 Removal of the drain without doctors requests
 Failure to provide health education
 Incomplete or incorrect documentation
 Injury to patient when suture is not cut correctly
EQUIPMENT/STAFF:
 Sterile dressing tray / basic pack
 Extra kidney dish
 Artery forceps
 Pincet 2
 Stitch cutter/sterile scissors
 Cleaning solution (Sodium Chloride 0.9%) (checked against prescription chart and with Registered
Nurse)
 Sterile wound care product as requested by doctor / protocol
 Sterile gauze x 2 packs (in case of basic pack usage)
 Sterile gloves (to use in case of basic pack)
| Study unit 1
PROCEDURE: REMOVAL OF A VACUUM DRAINAGE DEVICE

ACTION RATIONAL
ASSESSMENT
1.  Identify the patient  Verification of the patient’s identity ensures that

the correct procedure is being done on the correct
patient
explain the procedure to be done experienced by patient and.
 To facilitate cooperation during the procedure
5.  Surgical history  Provide indication for drain insertion

 Confirming the area of drainage system insertion
site
6.  Check the patient’s prescription  For specific instructions regarding wound care and
chart removal of the drain
 Check for any allergies, specifically  To prevent any skin irritations or allergic reactions
related to the products being used caused by wound care products
for wound care
7.  Evaluate the patient’s nursing care  The care plan will determine the related factors for
plan the nursing diagnoses based on the patient’s
current status
8.  Check patient’s Fluid balance chart  To assess if drain is still patent
 Drainage within the last 24 hours will determine
whether the drain can be removed or not
(according to doctor’s prescription/protocol)
Assess patient for the following:
9.  Physical and psychological ability to  Disorientation might lead to contamination and

participate spillage
10.  Assess patient’s basic needs e.g. the  To decrease any discomfort and possible
need to use a bedpan/urinal disturbances during the procedure
11. Assess current dressing for the following:  To provide information regarding active bleeding
and infectious changes.
 Drainage: colour & amount
 Saturated dressings will indicate dressing change
 Bleeding
12. Assess the patency of the drainage  Blocked drainage systems might lead to hematoma
system e.g. formation at the surgical site.
 Free, untwisted and unkinked tubing promotes the
3
Le1 | Study unit 1
ACTION RATIONAL
 Suctioning is still maintained. drainage from the wound area

 Tubing must be free from twist
and kinks.
13.  Excuse yourself from patient,  Keeping patient informed regarding actions will
remove gloves and wash hands enhance cooperation
socially
PLANNING
2.  Provide patient with privacy where  Patient always has a right to privacy
needed  To prevent unnecessary exposure e.g., abdominal
drainage systems
IMPLEMENTATION
1.  Remove linen without exposing the  Medico-legal requirement to always protect

patient unnecessary patient’s rights
2.  Put on unsterile gloves  To protect yourself from contact with bodily fluids
of patients
3.  Place linen saver under drainage  Linen saver protects underlying surfaces
container
4.  Close the clamp of drainage system /  This will stop the suctioning pressure
use artery forceps to clamp drainage  Prevent the entry of air into the drainage system
system and surgical site
5.  Release the vacuum by opening the  The spout cap needs to be opened to be able to
spout cap of the drainage system empty the drainage system
6.  Tilt the drainage system into the  Allowing the total amount of drainage to be
measuring jug collected into the measuring jug
7.  Wipe the outside of the device with  When drainage is present at the outside of the
paper hand towel without touching device area, linen will be contaminated with
the inside of the spout area and drainage.
clean the spout and cap with an  Touching the inside of the spout area will
alcohol swab contaminate a sterile environment
(This is only done if there is visible  Cleaning with an alcohol swab will prevent 4
drainage spillage in these areas) contamination of the valve and reduces the risk for
microorganism transmission
8.  Close the spout but do not create a  Creating a vacuum again might lead to possible
vacuum again tissue damage at surgical site when device is
removed
9.  Unclamp drainage system or release  To prevent loss of equipment when removed
artery forceps device is thrown in red bag
10.  Loosen the wound dressing/s  Dressings need to be loosened for easy access after
hands are washed aseptically
11.  Inspect dressing for characteristics  For early detection of possible infection
of drainage and the drain insertion
site and surrounding tissue for
clinical manifestations of infection
| Study unit 1
ACTION RATIONAL
12.  Go to the sluice and carefully  Drainage might consist of pus, fresh blood, old
measure the drainage in the darker blood, serous fluid or even some tissue.
measuring jar.  This is important information needed for the
Take note of the: attending surgeon to make decisions regarding the
drainage system
 Character
 Colour and
hands
14.  Prepare a sterile field on a dressing  To prevent the introduction of micro-organisms
trolley as for STERILE WOUND CARE into the wound drainage insertion site See WOUND
PROCEDURE CARE PROCEDURE
15.  Excuse yourself from the patient and  To prevent the introduction of micro-organisms
wash hands aseptically into the wound area
16.  Dry hands with sterile paper towels,  Being organized will ensure effective time
put on sterile gloves and organize management and prevention of unnecessary
field as with basic wound care contamination
procedure
17.  Remove old dressings with piece of  To have access to the drainage system area
sterile gauze/sterile cover of gloves  To ensure maintenance of sterility during the
procedure
18.  Create a sterile field at the patient  To ensure maintenance of sterility
side  A sterile field at the patient side will allow you to
place the kidney dish with the instruments needed
on the bed near to the drainage system area
19.  Provide wound care of the drain site  A drain is always considered as an infected wound
and therefore cleaned from the outside to the
inside
20.  Remove suture if present with Pincet  The drain might be secured with a suture to
and stitch cutter/scissors. prevent accidental removal thereof and must be
removed for the drain to be able to come out.
 (Always place stitch cutter in under  To ensure that the minimal amount of unsterile
the suture, as closely to the skin as suture being pulled through the patient’s skin.
possible, pointing away from  To prevent injury to the patient
patient.
 Then cut away from patients’ skin

21.  Support the patients skin at the  Support might reduce discomfort during removal
insertion site with a sterile gauze for of the drain
drain removal
22.  Ask patient to slowly breath in and  When patient concentrate on breathing the
out while drain is removed anxiety and discomfort associated with the
procedure might be reduced
23.  Pull drain with the artery forceps  Using the artery forceps and the sterile gauze will
slowly with a “S” motion until out prevent contamination of your sterile hands as you
5
Le1 | Study unit 1
ACTION RATIONAL
and grab the end thereof with the still need to attend to the surgical site dressing and
gauze in the non-dominant hand the drain insertion site
24.  Place the end of the drainage system  You still need to complete sterile wound care
into the kidney dish and if possible, procedure of the drainage insertion site and by
just cover with edge of the sterile placing the Portovac into the acceptor bag might
dressing towel on the patient’s bed jeopardize your sterility
25.  Take a sterile gauze and wipe the  To ensure that site is clean prior to placing the
drain site again dressing
26.  Place a new sterile gauze over drain  To absorb any extra drainage that might occur
site
27.  Apply adhesive dressing over gauze  To maintain a sterile occlusive environment,
on drain site preventing possible contamination
28.  Remove sterile field to dressing  Removing sterile field from patient’s bed will
trolley prevent the possible spread of micro-organisms
 Now the drainage system may be
placed into the acceptor bag.
29.  Tidy up as per basic wound care  To prevent the spread of micro-organisms
procedure
30.  Remove gloves and disinfect hands  To prevent transmission of micro-organisms
32.  Ensure patient safety by placing the  Patients need to be able to call for assistance STAT
bell within easy reach in case of abnormalities
 Patient has the right to be in a safe environment at
all times
33. Provide health education to the patient  To prevent medico-legal risks
regarding:
 patient must alert staff if he/she

sees/feels any drainage from the
drain site
34.  Report any abnormalities and action  To reduce medico-legal risks, the nursing student
need to report at all times 6
EVALUATION
1.  Evaluate the drain site after a ½ hour  For fast management of any abnormal active
for bleeding or drainage bleeding after procedure
DOCUMENTATION
Document the following on the PRESCRIPTION CHART:
1.  Signature at the correct date next to  For complete documentation

request for drain to be removed
Document the following on the FLUID BALANCE CHART:
2.  Amount measured under the  For complete and accurate documentation

correct column, at the correct time regarding drainage
space
| Study unit 1
ACTION RATIONAL

 Procedure done  NB! If not written, it is considered as not being
 Amount of drainage done
 Type of drainage
 Appearance of the insertion site
 Patient’s reaction
7
Le1 | Study unit 1
PEER ASSESSMENT
INSTRUMENT: REMOVAL OF VACUUM DEVICE

NAME OF STUDENT:
DATE:
ASSESSOR:
STUDENT SIGNATURE:
RESULT:

COGNITIVE COMPONENT
1. Provided 2 indications for removal of a
portovac drain
2. Provided 2 contra-indications for removal of a
portovac drain
3. Provided 5 medico-legal risks associated with
the procedure
ASSESSMENT
1. Patient identified
2. Introduced self to patient and explained the
procedure
4. Wash hands socially
5. Prescription chart checked A
6. Surgical diagnosis checked
7. Allergies specific to wound care products
B
checked
8. Patient care plan evaluated
9. Fluid balance chart checked for previous
A
amount of drainage
10. Patient assessed for the following
 Physical and psychological ability to 8
participate
 Basic needs
11. Disinfect hands and non-sterile gloves put on
12. Current dressing assessed for:
 Drainage, colour and amount
 Bleeding
13. Assessed the patency of the drainage system B
14. Excused self from patient, removed gloves and
washed hands socially
PLANNING
1. All equipment gathered as appropriate
2. Privacy ensured
| Study unit 1

3. Patient positioned accordingly
IMPLEMENTATION
2. Linen saver used to protect underlying surfaces
3. Disinfect hands and put on non-sterile gloves
4. Drainage system clamped B
5. Vacuum released
measuring jug
7. Outside of spout wiped with paper towel,
spout and cap cleaned with alcohol swab
8. Do not create vacuum again
9. Drainage system unclamped and artery forceps
B
removed
10. Loosen wound dressing/s
11. Wound areas assessed for:
 appearance of the wounds
 stages of wound healing
 characteristics of drainage
 clinical manifestations of infection
12. Remove gloves and wash hand socially
13. Sterile field prepared as per sterile wound care
B
procedure
14. Excused self from patient and washed hands
aseptically
15. Hands dried, sterile gloves put on and sterile
field organised as per sterile wound care
procedure
16. Remove current dressings in the correct
manner
17. Sterile field created at patient’s side
18. Sterile gauze put over drainage site and surgical
wound cleaned as per sterile wound care B
procedure
19. Sterile gauze put over cleaned surgical site
20. Drain site cleaned from outside to inside (septic
wound)
21. Suture removed in the correct manner (if
present)
22. Skin supported with sterile gauze at insertion
site in the correct manner
23. Patient educated to give deep, slow breaths
during removal of the drain
24. Drained pulled out with sterile artery forceps in
B
a “S” motion
25. End of drainage system placed into kidney
bowel and covered with sterile dressing towel
at bedside, without contaminating sterile
gloves
9
Le1 | Study unit 1

26. Drain insertion site wiped with clean sterile
gauze
27. New sterile gauze applied over drain insertion
site
28. Gauze removed from surgical wound site and
new dressing applied in the correct manner
29. Adhesive dressing applied over gauze on drain
insertion site
30. Drainage system placed into acceptor bag and
sterile field removed in the correct manner
31. Tidied up as per sterile wound care procedure
34. Health education provided
35. Patient bell placed within easy reach
36. Measure drainage in sluice. Take note of:
 Character
 Colour
37. Abnormalities and actions reported
EVALUATION
1. Surgical wound area and drain insertion site
evaluated after ½ hour for abnormal bleeding B
or drainage
DOCUMENTATION
2. Documented the following when portovac drain was removed and wound care was done:
Prescription chart: Date and time that drain
C
was removed with signature
Fluid balance chart: Amount measured B
Progress report:
 Date and time
 Procedure done
 Type of drainage
 Appearance of wound sites
 Clinical manifestations of infection 10
 Patients’ reaction
AFFECTIVE COMPONENT
____ X 100 = %
= 201 1
| Study unit 1
REMARKS
_______________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
____________________________________________________________________________________
11
Le1 | Study unit 1
FORMAL EVALUATION:
INSTRUMENT: REMOVAL OF A VACUUM DRAINAGE DEVICE

DATE:
NAME OF STUDENT:
STUDENT NUMBER
STUDENT SIGNATURE
EVALUATOR

COGNITIVE COMPONENT
1. Indications (2) for removal of a vacuum drainage
device
ASSESSMENT
5. Surgical history
7. Checked for allergies
11. Basic needs
12
13. Bleeding
C
PLANNING
2. Privacy provided
IMPLEMENTATION
| Study unit 1

5. Vacuum released
measuring jug
7. Outside of device wiped with paper towel, spout (Only in case of
and cap cleaned with alcohol swab spillage)
8. Spout closed without creating a vacuum again B
9. Drainage system unclamped B
10. Drain insertion site wound dressing loosened
11. The dressing, insertion site and surrounding
tissue inspected for:
 appearance of the insertion site
 characteristics of drainage
 clinical manifestations of infection
 Character
 colour
 amount
14. Sterile field prepared as per sterile wound care
procedure
15. Hands washed aseptically B
16. Hands dried, sterile gloves put on; sterile field
organised
17. Old dressing/s removed without contaminating
18. Sterile field created at patient’s bed side
19. Drain site cleaned in an aseptic manner
20. Suture around drainage tube removed correctly B
21. Skin supported with sterile gauze prior to
removal of drain
22. Patient requested to give deep, slow breaths
during removal of the drainage tube
23. Drained pulled out with sterile artery forceps in
a “S” motion
24. End of drainage system placed into kidney
bowel in the correct manner
25. Drain insertion site wiped with clean sterile
gauze
26. New sterile gauze applied over drain insertion
site
27. Adhesive dressing applied over gauze on drain
insertion site
28. Drainage system placed into acceptor bag and
sterile field removed in the correct manner
29. Tidied up as per sterile wound care procedure
13
Le1 | Study unit 1

EVALUATION
1. Drain insertion site evaluated after ½ hour for
C
abnormal bleeding or drainage
DOCUMENTATION
1. Prescription chart
Signature next to Dr. requests, correct date and C
time
3. Progress report:
 Date and time,
 Procedure done,
 Appearance of the drain insertion site and
surrounding tissue
 Patient’s reaction
AFFECTIVE COMPONENT
____ X 100 = %
= 1
(Subtract N/A from total) 14
REMARKS
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
___________________________________________________________________________________
| Study unit 1
STUDY UNIT 5: DERMATOLOGY
Study time
5.1Assessment of the skin

Learning outcomes
 Demonstrate an assessment of a patient’s skin.
 Identify and interpret abnormalities of the skin, based on the skin assessment
15
Le1 | Study unit 1
SKIN ASSESSMENT OF AN ADULT PATIENT
Outcome:
After completion of the practical programme, the student should be able to assess
an adult patient`s skin and identify the level of risk for developing pressure ulcers.
Assessment scale:
assessment
0 1 2 3
16
You have to obtain 50% of the outcome criteria to master the clinical skill and be declared competent.
Outcome criteria marked with an “A”, “B””or “C is considered a critical point. A critical point is any aspect
of a procedure which could severely jeopardise patient safety or result in patient death.
A = 25%
B = 15%
C = 5%
| Study unit 1
DEFINITION
A comprehensive skin assessment is a process in which the entire skin of a patient is examined for
abnormalities. It includes inspecting overall skin colour, inspecting the scalp and lesions or break down of
the skin. Palpation of the skin includes assessing temperature, moisture, texture, skin turgor, capillary refill
and oedema.
INDICATIONS FOR THE PROCEDURE

 On admission (with in first 8 hours)
 Daily based on patients’ risk of developing skin break down
- Malnourished patients
- Bedridden patients (sedated and paralysed)
- Obese patients
- Elderly patients
 In-patients transferred between wards
 Before patient is discharged
EQUIPMENT / STAFF
 Good lighting
 Wound measuring tool (measuring tape)
 Risk assessment tool (According to hospital protocols)
17
Le1 | Study unit 1
PROCEDURE: SKIN ASSESSMENT OF AN ADULT

ACTION RATIONAL
ASSESSMENT
1.  Identify the patient  Ensures that the correct procedure is being done
on the correct patient
explain the procedure to be done experienced by patient and.
 to ensure patient understand the procedure to be
done
5.  Surgical history and medical history  Surgical: Explain any operational scars on patients’
skin
 Medical: If patient is already diagnosed with a skin
condition (eczema, psoriasis etc.)
6.  Check the patient’s prescription  To identify any skin ointments or medication
chart patient has been treated with
 Nutritional status  To determine if the patient is well nourished
7.  Evaluate the patient’s nursing care  The nursing care plan will provide you with nursing
plan diagnosis, interventions and specific instruction on
how often skin assessment should be done
PLANNING
1.  Prepare environment  Privacy – Patient will be exposed, always
- Privacy ensure minimal exposure
- Room temperature  Room temperature – Temperature must be
- Good lightning warm, so it does not interfere with assessment
and ensure patient comfort
 Lightning – to be able to observe skin clearly
2.  Put on unsterile gloves  Protect yourself from bodily fluids
IMPLEMENTATION
1. INSPECTION:  Pallor – Reduced blood flow and oxygen or a
decrease in red blood cells (anaemia) 18
 SKIN COLOUR  Cyanosis- Decreased tissue supply of oxygen to
- Pallor tissues
- Cyanosis  Jaundice - Indicates liver disease (increased
- Jaundice bilirubin)
- Erythema  Erythema – Skin rash indicate due to reaction
- Ecchymosis to medication, disease, or infection
 Ecchymosis – Injury due to fall, bump or blow
to skin
2. SKIN INTEGRITY:  Lesions – Acne, blisters, cellulitis, scabies etc.
- Lesions  Skin breakdown- Peri-wound associated dermatitis
- Skin breakdown (erythema and maceration)
- Rashes - Peristomal dermatitis – due to urine or stools
- Petechia - Incontinence dermatitis – due to urine
- Unusual moles - Petechia – red, purple or brown spots due to Vit K
| Study unit 1
ACTION RATIONAL
- Burns and Vit C deficiencies
- Unusual moles: NB to take note of moles as the
presence can increase risk for melanoma, a
dangerous skin cancer.
- Burns: take note of size, depth, and drainage of
any burn wounds
3. PALPATION:  Temperature – Warmth, indicates infection or
- Temperature inflammation
- Moisture  Moisture:
- Skin turgor - Environmental factors – due to cold weather or
- Texture dry air. Skin appears scaly, red, and painful
- Oedema - Disease – eczema, dehydration or diabetes, lack of
- Capillary refill Vitamin B
- Clammy skin – acute allergic reaction,
hypoglycaemia, internal bleeding etc
 Skin turgor – Assess hydration status
 Texture – dry skin / moisture
 Oedema
- Grade 1 – 0-2mm indentation (rebounds
immediately
- Grade 2- 3-4 mm indentation (rebound <15
seconds
- Grade 3 – 5-6 mm indentation (rebounds up to 30
seconds)
- Grade 4 – 8 mm indentation (rebounds > 20
seconds)
 Capillary refill – Less than 3 seconds
hands
6.  Ensure patient safety by placing the  Patient has the right to be always in a safe
bell within easy reach environment
7.  Provide health education to the  Patient has a right to be informed
patient regarding abnormalities  To empower the patient and to prevent medico-
observed legal risks
8.  Report any abnormalities and action  Abnormalities to be immediately reported:

- Cool and clammy
- Diaphoretic
- Petechiae
- Jaundice
- Cyanosis
- Redness, warmth, and tenderness indicating a
possible infection
- Signs of pressure ulcers (Common on bony
areas)
EVALUATION
1.  Patient at risk for developing  To identify development of pressure ulcers early
pressure ulcers skin to be monitored
19
Le1 | Study unit 1
ACTION RATIONAL
twice a day
DOCUMENTATION
Document on risk assessment tools
1. Complete risk assessment tool  To identify risk level of patient losing skin integrity
(Addendum A) based on hospital
protocol
(Water low risk assessment scale or

Braden Q scale)
 Procedure done
 Abnormalities observed
20
| Study unit 1
Addendum A
Water low risk assessment tool
1
Le1 | Study unit 1
2
| Study unit 1
Braden Q risk assessment tool
1
| Study unit 1
PEER EVALUATION
INSTRUMENT: SKIN ASSESSMENT OF AN ADULT

DATE:
NAME OF STUDENT:
STUDENT NUMBER
STUDENT SIGNATURE
EVALUATOR

COGNITIVE COMPONENT
1. Indications (2) for assessment of the skin
ASSESSMENT
5. Surgical and medical history
8. Nutritional status
PLANNING
1. Prepare environment (Privacy/room
temperature/ lightning)
2. Put on unsterile gloves
IMPLEMENTATION
1. Inspect the skin colour:
- Pallor
- Cyanosis
B
- Jaundice
- Erythema
Ecchymosis
2. Inspect the skin integrity:
- Lesions
- Skin breakdown
- Rashes B
- Petechia
- Unusual moles
- Burns
3. Palpate skin for: B
- Temperature
- Moisture
1
Le1 | Study unit 1

- Skin turgor
- Texture
- Oedema
- Capillary refill
EVALUATION
1. Patient at risk for developing pressure ulcers
skin to be monitored twice a day
DOCUMENTATION
1.  Complete risk assessment tool C
2. Progress report:
 Date and time,
 Procedure done,
AFFECTIVE COMPONENT
____ X 100 = %
= 1
REMARKS
2
________________________________________________________________________________________
________________________________________________________________________________________
__________________________________________________________
| Study unit 1

SKIN ASSESSMENT
YES NO
2. Inspect skin colour
3. Inspect skin integrity
4. Palpate skin
5. Document finding on risk assessment tool
6. Identify whether patient is at risk
7. Document findings in progess report and report abnormalities
Signature of RN: ___________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
___________________________________________________________________________________
3
Le1 | Study unit 1
FORMAL EVALUATION
INSTRUMENT: SKIN ASSESSMENT OF AN ADULT

DATE:
NAME OF STUDENT:
STUDENT NUMBER
STUDENT SIGNATURE
EVALUATOR

COGNITIVE COMPONENT
1. Indications (2) for assessment of the skin
ASSESSMENT
5. Surgical and medical history
8. Nutritional status
PLANNING
1. Prepare environment (Privacy/room
temperature/ lightning)
2. Put on unsterile gloves
IMPLEMENTATION
1. Inspect the skin colour:
- Pallor
- Cyanosis 4
B
- Jaundice
- Erythema
Ecchymosis
2. Inspect the skin integrity:
- Lesions
- Skin breakdown
- Rashes B
- Petechia
- Unusual moles
- Burns
3. Palpate skin for: B
- Temperature
- Moisture
- Skin turgor
- Texture
| Study unit 1

- Oedema
- Capillary refill
EVALUATION
1. Patient at risk for developing pressure ulcers
skin to be monitored twice a day
DOCUMENTATION
1.  Complete risk assessment tool C
2. Progress report:
 Date and time,
 Procedure done,
AFFECTIVE COMPONENT
____ X 100 = %
= 57 1
REMARKS
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
___________________________________________________________________________________
5
Le1 | Study unit 1
STUDY UNIT 6: THEATRE NURSING
Study time
6.1Theatre nursing
Learning outcomes
 Discuss the difference between the theatre and a ward environment.
 Discuss and understand the roles of the following theatre personnel: the anaesthetic nurse, the floor
nurse (runner), the scrub nurse, the recovery room nurse.
 Discuss the basic drugs used in anaesthesia
 Explain the basic hygiene and aseptic principles in theatre (Infection control measures)
 Manage the sterile packs and instruments in theatre.
 Describe the general preoperative, intra operative and post-operative care of a patient scheduled for
theatre
WORKSHEET 6.1: THEATRE NURSING
Student name: ………………………… Student number: ……………………………

Institution: ………………………… Date: …………………………….
1. Define:
Tourniquet and diathermy and their use in theatre:
……………………………………………………………………………………………………………………….………………….
……………………………………………………………………….…………….…………………. 6
………………………………………………………………………………………………………………..
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…………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………
………
2. Care of the anaesthetized patient:
…………………….………………….……………………………………………………………………….…………….………………….………………………………….
…………………………………….….…………….………………….
………………………………………………………………………………………………………………………………………………………………………………………
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| Study unit 1
……………………………………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………………………….
3. The importance of counting swabs and checking of instruments during an operative procedure:
……………………………………………………………………………………………………………………….………………….
……………………………………………………………………….…………….………………….
………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………………………………………………………
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…………………………………………………………………………………………………………………………………………………………………………………
………
4. Describe the management of deceased patients in theatre: …………………….………………….

……………………………………………………………………….…………….………………….
……………………………………………………………………….….…………….………………….
……………………………………………………………………….
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5. Describe the management of amputated limbs in theatre:
…………………….………………….……………………………………………………………………….…………….………………….
……………………………………………………………………….….…………….………………….
……………………………………………………………………….
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…………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………
…………………………………..
6. Describe the special preparations necessary for:
(1) septic cases
…………………….………………….……………………………………………………………………….…………….………………….…………………………………..
…………………………………….….…………….………………….
……………………………………………………………………………………………………………………………… …………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………
(2) cases needing sterile conditions in theatre. Give examples of such cases: …………………….………………….
……………………………………………………………………….…………….………………….…………………………………..…………………………………….….
7
Le1 | Study unit 1
…………….………………….
………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………..
WORKSHEET 6.2: INTRA-OPERATIVELY
During your placement as a student nurse in theatre, observe how the theatre environment differs from a
ward environment and discuss the following topics.
You are allowed to use multiple resources (textbooks, multidisciplinary team, articles etc.) to complete this
task.
Questions:
1. Discuss the roles and duties of the anaesthetic nurse, the floor nurse, the scrub nurse, and the
recovery room nurse.
……………………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………….
8
……………………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………….
2. Discuss the different types of anaesthesia used in theatre.
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
| Study unit 1
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………….
3. Explain how basic hygiene and aseptic techniques is maintained in theatre.
……………………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………….
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………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………….
4. Describe infection control measures that would be in place in theatre.
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………..
5. Discuss the nurse’s duties in preparing the theatre preoperatively

………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
9
Le1 | Study unit 1
………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………….
6. Describe the procedures of scrubbing, gowning and gloving.
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
7. Explain the different operative positions a patient may be placed in during surgery.
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………..
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
8. Discuss the skin preparation and draping techniques of a patient on the theatre table.
10
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………..
| Study unit 1
9. Discuss the handover of a patient from the ward personnel to the theatre personnel. (What
information should be handed over?)
……………………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………….
11
| Study unit 1
6.3 INFORMAL PROCEDURES: THEATRE NURSING
THEATRE CLINICAL SKILLS
PROCEDURE DATE WARD/UNIT SIGNATURE: RN/DOCTOR
6.3.1 Receiving patient pre-operatively and checking consent
6.3.2 Opening sterile packs and adding extra sterile stock
6.3.3 Checking anaesthetic tray and equipment
6.3.4 Witness endotracheal intubation
6.3.5 Assist anaesthetist during surgery
6.3.6 Surgical instrument count
6.3.7 Surgical swab count
6.3.8 Receive patient post0operatively and nurse in recovery room
1
| Study unit 1
STUDY UNIT 7: PATIENT STUDY
Study time
7.1Patient study
Learning outcomes
 Obtain history of a patient (medical, surgical, pharmacological etc)
 Identify diagnostic tests conducted on patient
 Conduct a physical assessment of patient
 Formulate nursing diagnosis based on physical assessment and draw up a nursing care plan
PATIENT STUDY GUIDELINES
INSTRUCTIONS:
 Students should work in pairs no individual patient studies will be marked.
 The focus of your study should be on conditions covered in the 2nd semester.
 The number of pages of your case study should not exceed 8 pages, which will include the cover page,
table of contents and references (i.e. the body of the case study should be limited to 5 pages – case
study exceeding this limit will not be marked).
 The appendices pages (e.g., pharmacology) are not included in the 8 pages.
CONTENT OF THE CASE STUDY:
1. Assessment and Planning

1.1. Collect and interpret RELEVANT data
 History - reason for admission and hospitalization
 Biography – name, age, language, place of residence
 Family history – e.g., Diabetes Mellitus, Hypertension, etc.
 Medical / Surgical history – risk factors derived from this
 Social history – exercise, sleep, eating habits, weight, work, etc.
 Vital signs – previous and current – interpret changes/ abnormalities
1.2 Identify specific risk factors (from medical, surgical and social history)
 E.g. Smoking, stress, environmental exposure (social history) related to specific disease
1
Le1 | Study unit 1
 Explain how risk factors relate to the diagnosis of the patient
2. Evaluate the implementation of management and care
2.1 Evaluate medical interventions

 Diagnostic tests
 Pharmacological management
- Tabulate the following: name, type, dosage, indications, contraindications, actions, side effects
- Attach this as an appendix
 Intravenous fluid therapy
 Nutritional plan
2.2 Evaluate multidisciplinary team involved in patient`s management.

 Physiotherapy
 Dietetics treatment
 Referrals to community resources
 Occupational Therapy
 Social Work/ Counselling
If patient has not met any of the above, comment on why you think the multidisciplinary contact is needed,
and how it could benefit the patient.
2.3 Evaluate and interpret nursing actions

2.3.1 Comment on nursing care plan, e.g. the effectiveness of the nursing care, and identify priorities,
strengths and weaknesses of the care. Make recommendations to address shortcomings, e.g. did the care
plan address patient needs such as physical, emotional, spiritual and psychosocial needs?
2.3.2 Evaluate Ethical/legal/safety aspects of patient care.
Comment on aspects such as:
 Identification
 Communication skills – language
 Patient rights – respect, dignity, privacy, etc.
 Record keeping
Any other relevant ethical/legal/safety issues. Refer to example of the nurses’
scope of practice and other health legislation.
2.4 Appropriate health education that you would give to this specific patient / family. Must be
correct and specific to problems/risk factors. Identify health education strategies already in place for this 2
patient. If there are none, identify what health education strategies could be implemented for this
patient.
3. Conduct a physical assessment on the patient and identify two PRIORITY nursing diagnosis
4. Formulate a nursing care plan based on nursing diagnoses identified. (Table format)
| Study unit 1
PATIENT STUDY ASSESSMENT TOOL / MARKING RUBRIC

Aspects to assess Allocated marks Student marks
1. Technical presentation (14 marks)
 General presentation 2
 Table of content 1
 Font: Arial; Font size: 12; Line spacing 1.5 1
 Page numbers 1
 Academic writing 2
 Referencing (Articles/books) 5
- Correct referencing list (NWU Harvard)
- Correct in-text referencing
 Introduction and conclusion 2
2. Assessment and planning (20)

 Relevant data gathered 10
 Risk factors identified and interpreted 10
3. Evaluation of management and care (30)

 Evaluate medical interventions 10
 Evaluate multidisciplinary team involvement 10
 Interpret and evaluate nursing actions and care plan 10
4. Physical assessment (15)

 Physical assessment done systematically, and all systems 15
assessed (head-to-toe assessment)
 Prioritize the system that is affected
5. Formulate a nursing care plan (21)

 Formulate 3 nursing diagnosis based on the assessment 3
 Formulate 3 nursing interventions for each nursing diagnosis 9
 Formulate 3 rationale for each intervention 9
TOTAL MARK: 100
Remarks:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________
Lecturer / preceptor signature: _______________________________________________

Date: _____________________________________
3
Le1 | Study unit 1
DECLARATION OF HONESTY
Module code:. .........................
Student name: .........................
Student number: .........................
I;
hereby declare that this

Practical report *
Assignment *
Paper *
Portfolio * (*mark ONE applicable item)
is my own, original work.

I further declare that:
1. No part of it has been copied from another person Yes/No,
2. I acknowledged all consulted sources in the text and submitted a
Bibliography list, Yes/No
3. Parts without references are my own ideas, arguments, and conclusions Yes/No.
I understand that I may be charged with academic misconduct and/or plagiarism and that a disciplinary
hearing may be brought against me if this declaration is false.
SIGNED: ………………………… DATE: …………………………..

NSMP 321 2022 - Study Guide (Final)

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NSMP 321 EC

NURSING SCIENCE PRACTICE:

Dit begin alles hier

Gotlhe go simolola fano

Module name Nursing Science Practice: Medical & Surgical III

Use this guide concurrently with the theoretical guide

Additional resources Access to the Internet, eFundi and study material

Name of lecturer Ms. Tabea Motsilanyane

Email address 22063447@nwu.ac.za

On appointment. A day for student weekly consultation will

Access to the Internet, eFundi and study material indicated

Name of lecturer(s) Mr. Boitumelo J Molato

Email address 17137187@nwu.ac.za

On appointment. Student may request an appointment via

Name of lecturer(s) Mr. Tumelo Dintwe

Email address Tumelo.Dintwe@nwu.ac.za

On appointment. Student may request an appointment via

Name of lecturer(s) Dr. N Scheepers

Email address 26028573@nwu.ac.za

On appointment. Student may request an appointment via

Name of lecturer(s) Dr. A van Wyk

Email address 10095039@nwu.ac.za

On appointment. Student may request an appointment via

Name of lecturer(s) Mrs. Naomi Mahaswa

Email address 24556874@nwu.ac.za

On appointment. Student may request an appointment via

On completion of this module students should be able to demonstrate:

Books: (In alphabetic order)

1. The neurological system 1.1 Neurological assessment of an adult (FORMAL)

2. The renal system 2.1 Renal unit visit (Dialysis) (INFORMAL)

2.2 Understanding fluid balance chart (INFORMAL)

3. Gastrointestinal system 3.1 Changing of Total Parental Nutrition (TPN)

4. The reproductive system 4.1 Vacuum drain maintenance (FORMAL)

5. Dermatology 5.1 Assessment of the skin (FORMAL)

6. Theatre Nursing 6.1 Informal theatre skills

7. Patient presentation 7.1 Group assignment (case study) FORMAL

 Supervised clinical learning in clinical facilities

Potchefstroom campus students:

NSMP 321 GENERAL INFORMATION

Family responsibility leave

Signing off practical procedures

Instruction and guidance

STUDENTS WITH LEARNING DIFFICULTIES AND DISABILITIES

WARNING AGAINST PLAGIARISM

Vir meer inligting besoek die NWU-skakel vir plagiaat.

PROCEDURES SIMLAB DEMONSTRATIONS

STUDY UNIT 1: THE NEUROLOGICAL SYSTEM

1.1 Neurological assessment of an adult

At the end of this study section, you should be able to:

 Understand the completion and interpretation of a Glasgow Coma Scale

 Know the indications for performing a neurological assessment on an adult patient

NEUROLOGICAL ASSESSMENT OF THE ADULT PATIENT

DEFINING A NEUROLOGICAL ASSESSMENT:

INDICATIONS FOR THE PROCEDURE:

MEDICO-LEGAL RISKS INVOLVED:

 Misdiagnosing due to poor examination skills

PROCEDURE: NEUROLOGICAL ASSESSMENT OF THE ADULT PATIENT

 Assessing the motor response will indicate that

APPENDIX A – GLASGOW COMA SCALE

OUTCOME CRITERIA 0 1 2 3 REMARKS

CALCULATION OF MARK: Total marks on Evaluation scale

PROCEDURE SIGNED OFF BY PROFESSIONAL NURSE

Signature of RN: ___________________________